REGISTRATION FORM Moving Forward: Creating a Community

REGISTRATION FORM
Moving Forward: Creating a Community Response to Cyberbullying
May 15, 2015
9:00 a.m.-4:00 p.m.
(Registration and Check in 8:30-9:00)
Lunch provided: 12:00 p.m.- 1:00 p.m. Continuing Education Workshop, 9:00 a.m.-4:00 p.m.
Name: ______________________________________________________________________________________
Title (Ph.D., M.S., etc.): ____________________________________
Date of Birth: _____________________
Address: _______________________________________________
City/State/Zip: ___________________________________________
Telephone (office): _________________________
Fax: _________________________
E-mail: _________________________________________________
Do you need information about child care?
Yes No
School Psychologists and others who need Act 48 CE Credits required by the Department of Education, please provide
your Professional Personnel ID number:____________________________________.
REGISTRATION FEES (Circle all those that apply)
NWPPA/PPA Member
Non-Member
Student Member
Student Non-Member
Discounted
Registration*
$65
$80
$20
$25
Regular
Registration
$75
$90
$30
$35
CE/48 credits (non-PPA Members only)
$10
$10
CE/48 credits (PPA Members only)
$0
$0
* Discounted Registration ends May 1, 2015.
Total Enclosed (checks only, payable to ‘Penn State’) _______________________.
Send completed form with payment to:
Melanie D. Hetzel-Riggin, Ph.D.
Prevention of Aggression Resource Center
Penn State Erie, The Behrend College
4701 College Drive
Erie, PA 16563
NO registrations will be processed without completed registration and payment.